[Feature Illustration: Katherine Streeter for NPR]
In recent months, media outlets have surfaced a series of racist yearbook photos — including those of statewide elected officials in Florida and Virginia. In Virginia, the governor’s medical school yearbook brought us back to 1984 when a future physician, who would later become governor, chose to dress as a member of the Ku Klux Klan alongside another classmate who disguised himself in blackface.
Photos like these add to a vivid collage that forces us, as the American public, to witness and grapple with the extensive reach of racism and racist symbols. But the distinctiveness of this particular photograph extends further than the governor’s status as an elected leader. It also gives us a glimpse into aspects of the medical sector that reinforce many individuals’ trepidation to engage with it.
This isn’t ancient history or a description of the way things once were; it’s right here with us in 2019. And we shouldn’t be surprised by these blemishes, either: racism in healthcare dates back more than 2,500 years — and continues to disproportionately affect African Americans today. Aaron Carroll’s recent New York Times article “Doctors and Racial Bias: Still a Long Way to Go” clearly illustrates the breadth and depth of the racial prejudice that permeates modern care delivery. Carroll validates the qualms, concerns and even phobias that many people from marginalized communities have and continue to carry about the healthcare system.
For those of us who advocate for the integration of medical and social care — and for all the implementers, evaluators and policymakers with a stake in this work — this reality cannot be ignored. As we advance important efforts that address social risks and protective factors, we must also recognize the racial bias that persists within healthcare and learn not to repeat the mistakes of the past.
Carroll references several studies that highlight how racism has pervaded our healthcare system — and how its remnants and residue continue to stain it today. Among them is the well-known, unethical United States Public Health Service study of syphilis at Tuskegee, in which African American males were misled to believe that they were receiving free medical care for syphilis when there was no drug of choice for syphilis at the study’s commencement. Some may suggest that we have progressed tremendously since the Tuskegee study, and in some ways we have. Yet research consistently shows that implicit bias continues to be pervasive in healthcare.
Implicit bias for years has infected the delivery of medical services, and has led to a host of negative effects on clinical decision making, diagnosis, and the type of care provided to African Americans and other people of color. Inversely, studies reveal the more positive perception that physicians tend to have towards white patients. Dr. Camara Jones’ three levels of racism framework indicates that the racial bias found in healthcare most likely presents as forms of personally-mediated or internalized racism. And institutionalized racism, which is responsible for the structural barriers that create inequitable care delivery along racial lines, directly informs personally-mediated and internalized racism. Jones’ therefore argues that it is crucial to tackle institutionalized racism first.
The studies highlighted by Carroll help to solidify two terms used in our healthcare system that are tied directly to institutionalized racism: “health disparities” and “health inequities”. Yet these aspects of healthcare are too often detached from overall health policy, research and operational conversations. Given the presence of racial bias in care delivery, we cannot limit or conflate efforts to tackle social determinants of health as addressing racial disparities or promoting health equity. Developing an initiative focused on addressing social risks and protective factors cannot be the sole approach to tackle the broader, systemic challenges, as it ignores the need for health systems and providers to face the ways in which they contribute to these inequities. Instead, the approach can inherently place the “blame” for these disparities on the patient.
“Addressing health equity is unlikely to occur without explicit focus. Making health inequities worse is an important concern.”
— Dr. Kirsten Bibbins-Domingo, Chair
Committee on Integrating Social Needs Care into the Delivery of Healthcare
National Academies of Sciences, Engineering and Medicine
That’s why the design and execution of these programs matters so greatly. For example, just asking patients about their social needs can have unintended consequences, as highlighted in 2016 in the Journal of the American Medical Association. The authors’ recommendation of “not limiting screening of social needs based on apparent social status” is rooted in addressing implicit bias that may stem from various forms of discrimination, including racism. With the healthcare system’s history of racial bias, it is important that initiatives focused on addressing social risks and protective factors avoid the adverse effect of reinforcing and underscoring negative stereotypes that are often associated with people of color.
The healthcare system cannot take on the new responsibility of social care while accepting different outcomes for different races. Implementers, evaluators and policymakers must be deliberate and forthright to ensure that the execution of essential needs initiatives promote equity and alleviate disparities. The damaging effects of racial bias cannot be ignored in the scope of our work in social determinants of health.
Continuous dialogue is needed to avoid the unintended consequence of reinforcing racial bias. Anyone who hopes to make certain their social/essential needs efforts intersect with equity should consider these critical questions:
- Inclusive Input & Feedback: How are the voices of people of color brought into and heard in the design and the improvement of essential needs initiatives?
Are there ways to bring more voices into the conversation for design or improvement?
- Population Screened: Are screening efforts (essential needs assessments) being conducted for all patients?
And if not, what is the rationale for selecting our patient population?
- Staff Training: What type of training is given to staff and providers to ensure that essential needs assessments and navigation efforts are not reinforcing racial bias?
- Patient Experience: What are patients’ experiences being screened and having their essential needs met?
Does this experience differ by race/ethnicity? Does this experience differ when we explore the intersection of race/ethnicity with an individual’s gender, age, sexual orientation, socioeconomic status or immigration status?
Does this experience differ by the types of essential needs patients have?
- Addressing Resource Availability: How are differences in community resource availability being assessed and considered when determining the effectiveness of initiatives that tackle essential needs?
- Program Evaluation: Are we understanding the effectiveness and efficiency of our essential needs initiatives for various racial/ethnic groups?
Do we see disparities in our outcomes based on racial/ethnic groups? In our work, are we understanding disparities within the intersections, as well (i.e. the intersection race/ethnicity and gender, age, sexual orientation, socioeconomic status or immigration status)?
What measures can be developed that help us understand equity?
- Influencing Systems Change: How can we use essential needs initiatives — particularly process and outcome data — to shape policies in an effort to address the institutionalized racism found within and outside of the healthcare system?
Have you considered these opportunities to promote equity intentionally within your work to address essential resource needs?